CT of intracerebral haemorrhage due to mycotic aneurysms—Case report

Summary The CT findings in a case of intracerebral haematoma due to rupture of a mycotic aneurysm are presented. In addition to the haematoma, CT demonstrated small focal areas of cortical enhancement, which corresponded to the peripheral aneurysms seen on angiography. Such findings are thought to be characteristic; a brief differential diagnosis is discussed.     

Late CT manifestations in spontaneous putaminal haemorrhage

Summary Serial CT studies were performed on 61 patients with putaminal haemorrhage, to determine outcome. The average duration of the follow-up was 2 years and 5 months. Several types of late CT change were identified, including disappearance of the haematoma without a trace of haemorrhage, a residual cavity, deformity of the lateral ventricle, atrophy of the head of the caudate, white matter degeneration and linear pseudocalcification around the cavity. Small haematomas, comma-shaped and less than 2 cm wide might disappear without leaving any trace. A slit or small rounded residual cavity was a frequent result of elliptical or irregular haematomas with little mass effect. With prominent ventricular compression, there were distortion and dilatation of the lateral ventricle and atrophy of the head of the caudate nucleus, which might be accompanied by white matter degeneration and pseudocalcification around the cavity. Five cases (8%) were left with no trace of previous haemorrhage, 32 (52%) with a slit cavity, 10 (16%) with a small round cavity, 8 (13%) with a large cavity, 5 (8%) with no residual cavity but with ventricular deformity, and 1 (3%) with only pseudocalcification at the site of the haemorrhage.     

Detection of intracranial aneurysms with multislice CT: comparison with conventional angiography

We assessed the diagnostic accuracy of multislice CT in detection of intracranial aneurysms in patients presenting with subarachnoid or intracranial haemorrhage. Multislice CT and multiplanar digital subtraction angiography (DSA) images were obtained in 50 consecutive patients presenting with subarachnoid (SAH) and/or intracranial haemorrhage and reviewed by three neuroradiologists for the number, size and site of any aneurysms. The CT data were assessed using multiplanar reformats (MPR), maximum-intensity projections (MIP), surface-shaded display (SSD) and volume-rendering (VRT). In conventional angiography 51 aneurysms were detected in 41 patients. CT angiography (CTA) showed up to 48 aneurysms in 39 patients, depending on the observer. The overall sensitivity of multislice CT was 83.3% for small (<4 mm), 90.6% for medium-size (5–12 mm) and 100% for large (>13 mm) aneurysms. The sensitivity of multislice CTA to medium-size and large intracranial aneurysm is within the upper part of the range reported for helical single-slice CT. However, as small aneurysms may not be found, DSA remains the standard technique for investigation of SAH.     

CT appearances of haematomas in the corpus callosum in patients with subarachnoid haemorrhage

Corpus callosum heamatoma is a rare feature in subarachnoid haemorrhage (SAH), which may result from aneurysms of the anterior communicating artery (ACoA) or pericallosal artery (PCA). In 348 patients with aneurysmal SAH, bleeding from ACoA aneurysms in 88 cases produced no abnormality on CT in 7. Blood in the cistern of the lamina terminalis was the most frequent abnormality (76/88); haematomas of the septum pellucidum, confined to patients with ACoA aneurysms, were seen in 26 (30%). Rupture of PCA aneurysms in 12 patients gave rise to blood in the pericallosal cistern, anterior interhemispheric fissure and cistern of the lamina terminalis in 11. There was no blood in the septum pellucidum or the ventricular system in any case, but haematomas in the corpus callosum occurred in 8 (67%). In all of these, blood extended into the anterodorsal aspect of the callosum and spread posteriorly along its dorsal border. An identical, supracallosal pattern was seen in 2 patients (2.5%) with ACoA aneurysms, in whom haemorrhage was more extensive, with a large frontal lobe haematoma extending up from the cistern of the lamina terminalis in 1 and a haematoma of the septum pellucidum, with intraventricular extension in the other. In 8 patients (9%) with ACoA aneurysms a corpus callosum haematoma appeared to result from passage of blood up through the cistern of the lamina terminalis into the septum pellucidum and thence into the ventral aspect of the anterior corpus callosum; blood was present within the cistern, the septum and the ventricles.     

Three-dimensional CT angiography of intracranial vasospasm following subarachnoid haemorrhage

We evaluated the usefulness of three-dimensional CT angiography (3D-CTA) in the diagnosis of intracranial vasospasm following subarachnoid haemorrhage (SAH) in 13 patients suspected of having vasospasm on clinical grounds. The intracranial vessels were clearly shown by 3D-CTA in 12 patients. 3D-CTA revealed spasm in the vessels of nine patients. Catheter angiography performed in seven of these patients immediately after 3D-CTA confirmed vasospasm. A low-attenuation area was seen on CT in the other two patients, representing an ischaemic lesion due to the spasm. In nine patients, a second 3D-CTA was performed using the same technique 1 week after the first, showing no vasospasm. Initial 3D-CTA revealed no vasospasm change in three patients. Following 3D-CTA, one of these had conventional angiography, which also demonstrated no spasm.     

Detection and evaluation of intracranial aneurysms with 16-row multislice CT angiography

AIM: The aim of this study was to assess the usefulness of 16-row multislice CT angiography (CTA) in evaluating intracranial aneurysms, by comparison with conventional digital subtraction angiography (DSA) and intraoperative findings. METHODS: A consecutive series of 57 patients, scheduled for DSA for suspected intracranial aneurysm, was prospectively recruited to have CTA. This was performed with a 16-detector row machine, detector interval 0.75 mm, 0.5 rotation/s, table speed 10mm/rotation and reconstruction interval 0.40 mm. CTA studies were independently and randomly assessed by two neuroradiologists and a vascular neurosurgeon blinded to the DSA and surgical findings. Review of CTA was performed on workstations with an interactive 3D volume-rendered algorithm. RESULTS: DSA or intraoperative findings or both confirmed 53 aneurysms in 44 patients. For both independent readers, sensitivity and specificity per aneurysm of DSA were 96.2% and 100%, respectively. Sensitivity and specificity of CTA were also 96.2% and 100%, respectively. Mean diameter of aneurysms was 6.3mm (range 1.9 to 28.1 mm, SD 5.2 mm). For aneurysms of less than 3 mm, CTA had a sensitivity of 91.7% for each reader. Although the neurosurgeon would have been happy to proceed to surgery on the basis of CTA alone in all cases, he judged that DSA might have provided helpful additional anatomical information in 5 patients. CONCLUSION: The diagnostic accuracy of 16-slice CTA is promising and appears equivalent to that of DSA for detection and evaluation of intracranial aneurysms. A strategy of using CTA as the primary imaging method, with DSA reserved for cases of uncertainty, appears to be practical and safe.     

Significance of haemorrhagic lacunes on MRI in patients with hypertensive cerebrovascular disease and intracerebral haemorrhage

Our purpose was to determine the frequency and signifcance of haemorrhagic lacunes (HL) on MRI in patients with a history of, or at risk for intracerebral haemorrhage. We examined 72 patients with old spontaneous intracerebral haemorrhage (ICH) using T1-and T2-weighted spin-echo sequences. MRI studies of 137 consecutive patients with cerebrovascular disease but no known ICH were also reviewed. Both groups showed about the same degree of age-related white matter change and nonhaemorrhagic lacunar infarcts, whereas the ICH group had a higher frequency of HL (12/72 patients) than the non-ICH group (6/131 patients,p<0.01). These results correlate well with reported pathological findings. We conclude that haemorrhagic lacunes found on MRI studies of patients with cerebrovascular disease may suggest a higher risk of intracerebral haemorrhage.     

Delayed intracerebral hemorrhage as demonstrated by CT scanning

Summary Three patients are presented who developed delayed intracerebral hematomas after head injury. Two patients had essentially negative CT scans on admission and developed intracerbral hematomas within 24 h after injury. They required surgical treatment and had fatal outcomes. The third patient presented with an epidural hematoma on CT scan, developed an intracerebral hematoma 48 h after evacuation of the epidural hematoma, and did well with conservative management.     

Current diagnostic approaches to subarachnoid haemorrhage

Over the past decade, significant advances have been made in the field of subarachnoid haemorrhage (SAH). Prompt diagnosis with high-resolution CT and intensive critical care support remain key aspects of good patient management. Early identification and definitive treatment of underlying ruptured aneurysms is generally advocated to reduce the risk of re-bleeding, a complication with high mortality and morbidity. Although intra-arterial digital subtraction angiography (DSA) is still considered the gold standard for sourcing aneurysms, CT angiography, especially with the evolution of multi-slice technology, is slowly gaining acceptance as a rapid, accessible and minimally invasive method which appears likely to replace DSA as first-line modality in the future. Furthermore, the advent of Guglielmi detachable coils and the ISAT trial have revolutionised the treatment of ruptured aneurysms, with a significant trend towards endovascular coiling away from operative clipping. Improvements in clinical experience, coiling technology and assistive devices now allow interventionalists to potentially treat the majority of aneurysms, including wide-necked or complex lesions. The uncertain long-term results of coiling, however, still fuel strong debate and controversy. This review summarises current diagnostic approaches to SAH from a radiological perspective, with an emphasis on aneurysmal SAH and an evidence-based approach to the role of imaging and interventional radiology in diagnosis, treatment and follow-up.     

高血压脑出血的CT评价(附77例报告)

目的探讨高血压脑出血的CT表现。方法采用螺旋CT扫描,分析了77例高血压脑出血患者的发病年龄、出血部位和出血量。结果 77例患者的发病年龄段以50～69岁最多,共42例,占54.55%;70～86岁年龄段次之,共28例,占36.36%。以外囊出血最多,有21例(占27.27%),其他部位出血病例数依次递减:丘脑12例,混合出血11例,内囊出血10例,小脑出血6例,脑干和三角区出血各5例,其他部位3例。出血量在0～19 mL44例(占57.14%),20～29 mL7例,30～49 mL13例,50～99 mL6例,100 mL或以上仅有3例(占3.90%),有4例脑室出血量无法计算。结论 CT检查可为临床及时诊断和治疗高血压脑出血提供科学依据。     

The need for repeat angiography in subarachnoid haemorrhage

This study was designed to assess the necessity for a second angiogram study in patients in whom initial angiography after primary subarachnoid haemorrhage (SAH) was negative. During a 12-year period, 122 of 694 patients (17.5 %) had negative initial angiograms. CT, available for 98 patients, showed a preponderance of subarachnoid blood in the perimesencephalic cisterns in 50 of 73 patients (68.5 %) in whom blood was visible on CT. Angiography, repeated in 67 patients, revealed an aneurysm in 4 (6 %): 2 had an aneurysm of the anterior communicating artery, 1 of the posterior inferior cerebellar artery, and 1 of the P2 segment of the posterior cerebral artery. CT showed subarachnoid blood in the interpeduncular and ambient cisterns in this last case, and a preponderance of subarachnoid blood outside the perimesencephalic cisterns in the remaining 3 patients. Received: 14 March 1997 Accepted: 2 May 1997     

Prediction of delayed neurological deficit after subarachnoid haemorrhage: a CT blood load and Doppler velocity approach

The predictive value of cranial computed tomography (CT) blood load and serial transcranial Doppler sonography for the development of delayed ischaemic neurological deficit was assessed in 121 patients following subarachnoid haemorrhage. Of the 121 patients, 81 (67%) had thick layers of blood or haematoma, including intraventricular bleeding. The proportion of patients who developed delayed deficit was higher with increasing amounts of subarachnoid blood on the admission CT (51% of 53 cases in Fisher grade 3; 35% of 33 cases in grade 2; 28% of 7 cases in grade 1,P<0.01). Doppler velocities obtained from readings at least every 2 days following admission were higher in patients with delayed neurological deficit (peak velocity for grade 3 patients 176±6 cm/s (mean±SE), versus grade 2: 164±7 cm/s; grade 4 149±9, bothP=0.04, Mann-Whitney). Peak velocity and maximal 24-h rise tended to be higher within different CT grades in patients with a deficit than in those without; this difference was significant for grade 3 patients (P<0.01). We conclude that a combined approach with CT and Doppler sonography provides greater predictive value for the development of delayed ischaemic neurological deficit than either test considered independently. The value of Doppler sonography may be greatest for patients with Fisher grade 3 blood, in whom the risk of delayed ischaemia is greatest.     

脑内等密度占位性病变的CT诊断途径分析(附116例报告)

目的：分析总结脑内等密度占位性病变的CT征象及诊断途径，加强对此类疾病的认识，提高诊断准确率。方法：回顾分析经病理或治疗随访证实的116例脑内等密度占位性病变的CT征象特点，其中109例行CT增强检查。结果：116例中，确诊主要途径为：仅通过CT平扫确诊10例，结合CT平扫及增强确诊59例，结合病史确诊16例，结合临床查体确诊9例。结合其他影像或实验室检查确诊15例。脑瘤87例，其中胶质瘤34例、转移瘤31例、脑膜瘤10例、垂体瘸5例、其他7例，亚急性硬膜外或硬膜下血肿15例，脑脓肿7例，脑血管畸形4例，脑囊虫病3例。结论：通过仔细分析CT平片和全面结合病史、临床查体、其他检查，提示脑内占位性病变，并尽可能做出神经功能定位，再辅以CT增强，必要时随访，对于正确诊断脑内等密度占位性病变，减少漏诊，避免误诊，非常重要。     

Accuracy of intermediate dose of furosemide injection to improve multidetector row CT urography

OBJECTIVE: Evaluate the usefulness of intermediate dose furosemide to improve visualization of the intrarenal collecting system and ureter using MDCTU. MATERIALS AND METHODS: Two groups of 100 patients without urinary tract disease or major abdominal pathology underwent MDCTU. Group I (various abdominal indications) was performed without any additional preparation and Group II (suspicion of urinary tract disease) 10 min after injection of furosemide (20mg). MIP images of the excretory phase were post-processed. Maximal short-axis diameter of the pelvis and ureter were measured on axial images for all phases. Visualization of the collecting system wall and the identification of the whole ureter were assessed. RESULTS: Mean pelvic diameter before contrast was (7.4mm, S.D.+/-2.7; 13.4mm, S.D.+/-4.1), on cortico-medullary phase (8.4mm, S.D.+/-4.2; 14.3mm, S.D.+/-4), on nephrographic phase (8.1mm, S.D.+/-2.5; 14.8mm, S.D.+/-4) and on excretory phase (9.7 mm, S.D.+/-3.4; 14.9 mm, S.D.+/-4.5), respectively, for Groups I and II. Intrarenal collecting system wall was clearly identified on both corticomedullary and nephrographic phases in 91% of Group II against 20% of Group I. Opacification of the entire ureter was excellent on excretory phase in 96% of Group II against 13% of Group I. The difference between the mean values for the two groups was statistically significant for all phases (p<10(-9)). CONCLUSION: Intermediate-dose furosemide (20mg) before MDCTU is a very simple add-on for accurate depiction of pelvicalyceal details and collecting system wall without artefacts. The procedure is associated with a constant and complete visualisation of the entire urete.     

Flat-panel detector volumetric CT for visualization of subarachnoid hemorrhage and ventricles: preliminary results compared to conventional CT

INTRODUCTION: The aim of this study was to compare flat-panel volumetric CT (VCT) to conventional CT (cCT) in the visualization of the extent of subarachnoid hemorrhage (SAH) and the width of the ventricles in patients with acute SAH. METHODS: Included in the study were 22 patients with an acutely ruptured cerebral aneurysm who received VCT during coil embolization. VCT image quality, the extent of SAH (using a modified Fisher score and total slice number with SAH visible) and the width of the ventricles (Evans index) were evaluated by two experienced neuroradiologists (RAD1 and RAD2) and compared to the findings on cCT. Ten patients undergoing VCT for reasons other than SAH served as negative controls. RESULTS: Interobserver agreement in rating image quality was excellent for cCT (Kendall W value 0.94) and good for VCT (0.74). SAH was identified by RAD1 and RAD2 on VCT images in all patients. The modified Fisher scores underestimated the extent of SAH on VCT images in comparison with cCT images. Pearson's correlation coefficient (r) regarding the number of image slices with SAH visible on cCT images compared with the number on VCT images was 0.85 for RAD1 and 0.84 for RAD2. The r value for the degree of interobserver agreement for the number of slices with SAH visible was 0.99 for cCT, and 0.95 for VCT images (n=19), respectively. The width of the ventricles measured in terms of the Evans Index showed excellent concordance between the modalities (r=0.81 vs. 0.82). CONCLUSION: Our preliminary results indicate that VCT is helpful in evaluating SAH in the angiography suite. Additionally, reliable evaluation of ventricle width is feasible. However, there are limitations with regard to the visibility of SAH on VCT images in comparison to cCT images.     

Filling defect sign in CT diagnosis of ruptured aneurysm

We have encountered a ruptured aneurysm as a filling defect in cisternal blood on CT in patients with acute subarachnoid haemorrhage (SAH), as high-attenuation blood can act as a contrast medium. We term this finding the “filling defect sign”. To evaluate the usefulness of the sign in the diagnosis of a ruptured aneurysm, we retrospectively analysed CT with 10-mm-thick slices obtained within 2 days of onset of SAH in 100 consecutive patients. The sign was observed in 30 of the 100 patients, and in 13 (68 %) of 19 patients with a ruptured aneurysm more than 10 mm in diameter. The filling defect sign is useful in predicting the site of rupture. Received: 30 May 1996 Accepted: 6 September 1996     

CT angiography of intracranial aneurysms related to arteriovenous malformations: a cautionary tale

Computed tomographic angiography (CTA) has a high sensitivity and specificity for the detection of intracranial aneurysms and is increasingly used as the primary imaging modality in the investigation and pretreatment planning of patients presenting with acute subarachnoid haemorrhage. We present two cases in which CTA failed to demonstrate arteriovenous malformations associated with intracranial aneurysms.     

99mTechnetium HMPAO imaging in children with the Sturge-Weber syndrome: a study of nine cases with CT and MRI correlation

Demonstration of the full extent of abnormality in patients with the Sturge-Weber syndrome (SWS) is important for prognosis and in planning surgery to remove the seizure focus. We compared single-photon emission computed tomography (SPECT), MRI and CT in nine children under the age of 4 years with seizures as part of SWS, in an attempt to determine the optimal method of imaging in different clinical settings. Seven unilateral and two bilateral cases were studied by interictal ^99mtechnetium hexamethylpropyleneamineoxime (HMPAO) SPECT, and contrast-enhanced CT and MRI, giving information on 11 abnormal hemispheres. All imaging modalities showed abnormalities in every child. Perfusion imaging showed focal regions of decreased uptake in 9 of 11 (82 %) abnormal hemispheres and demonstrated a widespread decrease but no focal defect in 2; it also revealed crossed cerebellar diaschisis in 2 cases. CT demonstrated typical gyriform calcification in 9 of 11 (82 %) affected hemispheres. Contrast-enhanced MRI showed more extensive involvement than contrast-enhanced CT in 5 of 11 (45 %) cases. The area of hypoperfusion shown by SPECT was smaller than the area of contrast enhancement on MRI in 6 of 11 cases (55 %), comparable in 3 (27 %) and larger in 2 cases (18 %). CT is sufficient to confirm the clinical diagnosis of SWS, but MRI frequently shows more extensive abnormal areas. ^99mTc HMPAO imaging is a useful addition when it is important to know the full extent of the disease, for example prior to surgery. It is likely to detect areas of hypoperfusion, representing ischaemic regions, which may act as an epileptogenic focus and may not be shown by CT or MRI. Received: 31 August 1995 Accepted: 27 March 1996     

Subtraction CT angiography for evaluation of intracranial aneurysms: comparison with conventional CT angiography

The purpose of our study was to compare the diagnostic performance of subtraction computed tomography angiography (CTA) with conventional nonsubtracted CTA and digital subtraction angiography (DSA) for the detection of intracranial aneurysms. A total of 76 patients underwent both subtraction CTA and conventional CTA for the detection and therapy planning of suspected intracranial aneurysms. Subtraction and conventional CTA images were independently assessed by two readers in a blinded manner. The possibility of endovascular treatment or surgical clipping was also assessed based on information provided by CT angiograms alone. In 64 patients, 75 aneurysms were present on DSA. On a per-aneurysm basis, the sensitivity of subtraction CTA was 98.6% for reader 1, and 100% for reader 2. However, sensitivity of conventional CTA was 94.6% for reader 1, and 93.3% for reader 2. Therapeutic decisions could be made regarding 63 patients based on information provided by subtraction CTA images. However, conventional CTA provided sufficient information to make this decision for 55 patients. Conventional CTA has limited sensitivity in detecting very small aneurysms as well as aneurysms adjacent to bone. Subtraction CTA performed on a 64-row multidetector CT is an accurate and promising diagnostic tool that seems to be equivalent to 2D DSA for the detection and pretreatment planning of intracranial aneurysms.     

Computed tomography of intracerebral toruloma

Summary The CT features of intracerebral toruloma are described and the clinicopathological features briefly reviewed. The diagnosis of intracerebral toruloma should be considered when pulmonary opacities are associated with multiple intracerebral enhancing masses.